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Morbidity and Mortality Conference

Morbidity and Mortality Conference. Feb 13, 2002 Martin S. Rhee, MD. History of Present Illness. 54 year old female with ESRD presented with mental status changes Headache, neck discomfort x hours Confusion Fevers. Past Medical History. ESRD 2 ° to DM, HTN Hemodialysis

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Morbidity and Mortality Conference

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  1. Morbidity and Mortality Conference Feb 13, 2002 Martin S. Rhee, MD

  2. History of Present Illness 54 year old female with ESRD presented with mental status changes • Headache, neck discomfort x hours • Confusion • Fevers

  3. Past Medical History • ESRD • 2° to DM, HTN • Hemodialysis • DM II (non-insulin dependent) • HTN • PVD • s/p R above knee amputation after failed R femoral popliteal bypass (7 months prior) • Osteomyelitis of R stump post AKA

  4. Medications • Nephrocaps 1 tab PO qd • Doxepin PO qid prn • OCP(estradiol/progestin) ADR • Cefazolin (hives) • Morphine sulfate (nausea)

  5. Social History • Married • Lived with husband • Clerk • Cig: 2 ppd for 30yrs • EtOH: rarely

  6. Physical Examination • 100.9 102 (BP not recorded) • Gen: Somnolent but arousable, oriented • HEENT: PERRL, EOMI, OP-dry, clear • Neck-Discomfort with flexion, JVP-7cm, no LAD • Cor: RRR, normal S1/S2, no M/R/G • Lung: CTA bilaterally • Abd: Active BS, soft, nontender, no HSM, • Ext: No C/C/E • Neuro: CN-grossly intact, Motor-5/5 in UE/LE, Sensory-intact to light touch

  7. Laboratory Data 13.1 128 89 55 291 19.7 157 8.6 40.5 4.8 23 PTT: 40.6 PT: 11.7 INR: 1.1 CK: 160 CKMB: 14.92(<5.0) Tn: 0.13(<1.50) UA: Negative No initial CXR EKG(show)

  8. Admission EKG

  9. Initial Management • Fever & Mental Status Changes • Empiric levofloxacin given • Meningitis?, line infection?, pneumonia?, UTI?, infective endocarditis?, osteomyelitis? • Await for blood culture results • LP • Line removal if needed • Cardiac • Acute coronary syndrome • ASA, heparin, beta blocker • No thrombolytics

  10. HD #1-2 • Hypotensive episode (SBP 79) • IV dopamine, IV dobutamine • IV fluid: wide open • No CP, but persistent ST elevation • IV tirofiban added • New Afib: rate controlled to 60’s • BCx growing G(+) cocci • Abx changed to vancomycin • LP not done • Line removed after HD

  11. HD # 3-4 • Clinically improving • Tn < 1.50  21.8 • Resolving EKG changes • Off dopamine, dobutamine, heparin, tirofiban • BCx: Staph aureus

  12. HD #5-7 • Two episodes of R sided seizure • Phenytoin started • Slurred speech, R sided weakness • Head CT • 2.3cm hematoma on L frontal region • Transthoracic echo • Probable vegetation vs thrombus on MV • Transfer to DHMC CCU

  13. Medications on Transfer • ASA 81mg PO qd • Metoprolol 25mg PO bid • NTG paste • Vancomycin IV with HD • Rofecoxib • Fentanyl patch • Epogen

  14. Physical Examination • 36.5 69 120/70 20 98% on 6L • Gen: Ill appearing, somnolent, mildly confused • HEENT: PERRL, EOMI, OP-dry, clear • Neck: JVP-7cm, no LAD, supple • Cor:, RRR, no R/G, I-II/VI SEM on LSB • Lung: Slight bibasilar crackles • Abd: Soft, nontender, no HSM, active BS • Ext: Peripheral cyanosis, no C/E • Skin: No Janeway lesions/ Osler’s nodes/ splinter hemorrhage/ petechial lesions • Neuro: R sided weakness

  15. Laboratory Data 10.3 13393 53 5.723 7.1 518 11.5 111 34.4 PTT: 28 PT: 16.2 INR: 1.5 CK: <20 Tn: 2.57 (<0.03) ABG: 7.42/39/214 on 100% CXR: Unremarkable EKG: NSR, Q wave on III, nonspecific ST-T changes on precordial leads

  16. Laboratory Data • Staph aureus sensitivity • PCN resistant, oxacillin sensitive • TTE: • EF 60%, • Mitral valve mass consistent with a vegetation on the atrial aspect of the posterior leaflet • Apical HK • Minimal MR

  17. Assessment and Plan • Acute infective endocarditis complicated with septic emboli to heart and brain • Continue medical management • Abx changed to IV nafcillin • TEE • Continue ASA, beta blocker • No anticoagulation • Continue HD

  18. HD #2-3 • TEE: • Multiple vegetations on ant/post mitral leaflets on atrial side • Largest one 1.2 cm • No abscess, cavity or fistula • MV prolapse with trivial MR • Clinically improving • Transfer to floor

  19. HD #4-10 • Cyanotic R fingers • Doppler: Likely ulnar artery/palmar arch occlusion • Septic emboli most likely • Observation without any intervention • SOB with bibasilar crackles ½ up • Cor: 3/6 holosystolic murmur at apex • CXR: Pulmonary edema, small B pleural effusions • NTG drip • Repeat TTE • 2-3+ MR (worse than before) • BCx: NGTD

  20. Surgery for Acute Endocarditis • Operative mortality 4%-22% (active NVE) • Potential indications include: CHF, perivalvular disease, uncontrolled infection, PVE, two (or one) episode of embolization, certain organisms • Pseudomonas, brucella, Coxiella burnetii, fungi • CHF strongest indication • 56-86% mortality w/o surgery vs. 11-35% with surgery • Hemodynamic status is the principal determinant of operative mortality • Optimal time for surgery is before hemodynamic instability or perivalvular spread Mylokanis E, Calderwood S. Infective Endocarditis in Adults. NEJM 2001;18:1318-1330. Reinhartz O, et. al. Timing of surgery in patients with acute infective endocarditis. Journal of Cardiovascular Surgery 1996;37:397-400.

  21. HD #11-14 • No complaints • 150’s/90’s 90s 20 Tmax : 38.5 91% on RA • Gen: NAD • Cor: JVP-7cm, RRR, 3/6 holosystolic murmur • Lung: Bibasilar crackles • Ext: No edema • Bld Cx: NGTD • A/P: Persistent fever with endocarditis • Rifampin added • TEE (show)

  22. Transesophageal Echocardiogram

  23. HD #11-14 • No complaints • 150’s/90’s 90s 20 Tmax 38.5 91% on RA • Gen: NAD • Cor: JVP-7cm, RRR, 3/6 holosystolic murmur • Lung: Bibasilar crackles • Ext: No edema • Bld Cx: NGTD • A/P: Persistent fever with endocarditis • Rifampin added • TEE(show) • CT surgery consult  Proceed with surgery

  24. HD #15-23 • Operation • MV replacement (St. Jude) • Primary repair of posterior annular abscess • Transfer to CT ICU • Intubated, on pressor (milrinone) • Post Op TTE: Unremarkable • Clinically improving • Extubated on HD #17 • Heparin, coumadin started • Transfer to 4E

  25. HD #24 • Fever (T 39.8) • Repeat Bld Cx sent • Micro data • MV Cx: No growth • MV abscess Cx: Few Candida parapsilosis • ID consult • Polymicrobial endocarditis?, secondary seeding of vegetation by one of the organisms?, coincidental Staph aureus bactermia? • Start fluconazole

  26. Microbiologic Features of Native/Prosthetic Valve Endocarditis -ages 16 to 60- Pathogen NVE PVE* Approx. % of cases Strep 45-65 1 Staph.aureus 30-40 20-24 Coag-neg staph 4-8 30-35 Gram-negatives 4-10 10-15 Fungi 1-3 5-10 Polymicrobial 1-2 2-4 * Early, < 60 days after procedure Adapted from Mylokanis E, Calderwood S. Infective Endocarditis in Adults. NEJM 2001;18:1318-1330.

  27. HD #25 • Cross covering surgical housestaff called for fever (T 38.7), tachypnea (R 30-40) • Stat labs(CBC, lytes): Unremarkable • Blood cultures sent • Two hours later, pt in asystole • Epinephrine given, intubated • Palpable pulse with BP 160/80 • EKG: Complete heart block • Transfer to ICU

  28. HD #25 • Assessment • Progression of fungal endocarditis involving conduction system most likely • Temporary transvenous pacing attempted but unsuccessful • Micro data from 27hrs prior • BCx: Budding yeast and yeast with pseudohyphae

  29. HD #25 • CT surgery • Very poor prognosis • Not a candidate for reoperation • Pt in complete heart block • Family Meeting • Comfort measures only • Pt extubated • 6 hrs later, pt died peacefully • BCx: Candida albicans • No post-mortem examination

  30. TheNew England Journal of Medicine February 14, 2002 USE OF A STAPHLOCOCCUS AUREUS CONJUGATE VACCINE IN PATIENTS RECEIVING HEMODIALYSIS 11 26 P = 0.02

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